34635 WIM Equipment RFP_C Certifications and References.docx

RFP 34366 – Weigh-In-Motion Equipment Att C

ATTACHMENT C — PROPOSER INFORMATION AND CERTIFICATION SHEET

Legal Name of Proposer: ___________________________________________ Address: ______________________________________________________________ City, State, Zip: ____________________________________________ State of Incorporation: ____________________________________________ Entity Type: ________________________________________________ Contact Name:__________________________________________ Telephone: _________________________ Email: ____________________________ Oregon Business Registry Number:__________________________________ Any individual signing below hereby certifies they are an authorized representative of Proposer and that:

Proposer understands and accepts the requirements of this RFP. By submitting a Proposal, Proposer agrees to be bound by the Price Agreement terms and conditions in Attachment A and as modified by any Addenda, except for those terms and conditions that Agency has reserved for negotiation, as identified in the RFP.

Proposer acknowledges receipt of any and all Addenda to this RFP.

Proposal is a Firm Offer for 180 days following the Closing.

If awarded a Price Agreement, Proposer agrees to perform the scope of work and meet the performance standards set forth in the final negotiated scope of work of the Price Agreement.

I have knowledge regarding Proposer’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Proposer is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318. Proposer has no undisclosed liquidated and delinquent debt owed to the State of Oregon or any of its agencies, boards, commissions, departments or divisions.

Proposer does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Proposer does not discriminate against any business certified under ORS 200.055 as a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a business that a service-disabled veteran owns or an emerging small business. If applicable, Proposer has, or will have prior to contract execution, a written policy and practice, that meets the requirements described in ORS 279A.112 , of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class. Agency may not enter into a contract with an anticipated contract price of $150,000 or more with a Proposer that does not certify it has such a policy and practice. See https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx for additional information and sample policy template.

Proposer complies with ORS 652.220 and does not unlawfully discriminate against any of Proposer’s employees in the payment of wages or other compensation for work of comparable character on the basis of an employee’s membership in a protected class. “Protected class” means a group of persons distinguished by race, color, religion, sex, sexual orientation, national origin, marital status, veteran status, disability or age. Contractor’s continuing compliance constitutes a material element of the Contract/Price Agreement and a failure to comply constitutes a breach that entitles Agency to terminate the Contract/Price Agreement for cause.

Contractor may not prohibit any of Contractor’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Contractor may not retaliate against an employee who discusses the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person.

Proposer is not engaged in the provision of broadband Internet access service, or if at any time Proposer is engaged in or may engage in the provision of broadband Internet access service, Proposer is in compliance with Oregon Laws 2018, Chapter 88 (HB 4155) and applicable Public Utility Commission rules, and will remain in compliance throughout the term of the Contract/Price Agreement.

Proposer and Proposer’s employees, agents, and subcontractors are not presently debarred, suspended, proposed for debarment under ORS 279B.130, or declared ineligible for the award of contracts by any federal agency or agency of the State of Oregon and are not included on:

the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at: https://www.treasury.gov/ofac/downloads/sdnlist.pdf., or the government wide exclusions lists in the System for Award Management found at: https://sam.gov/SAM/ Proposer certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Proposer, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the RFP. If any changes occur with respect to Proposer’s status regarding conflict of interest, Proposer shall promptly notify the State in writing. Proposer has made all Conflict of Interest (COI) disclosures, if any as required by the ODOT COI Guidelines and COI Disclosure Form available at the following link: https://www.oregon.gov/ODOT/Business/Procurement/Pages/PSK.aspx) (Check one of the following two certifications as applicable) |_| Proposer understands and has provided to all Associates (as defined in the COI Guidelines) the COI Guidelines and COI Disclosure Form. Proposer and, to the best of the undersigned’s information, knowledge and belief, Proposer’s Associates are in conformance with the COI Guidelines, have no employees that were employed by ODOT within the last two-year period, and have no conflicts of interest or other disclosures required per the COI Guidelines or COI Disclosure Form.

|_| Proposer understands and has provided to all Associates (as defined in the COI Guidelines) the COI Guidelines and COI Disclosure Form. Proposer and, to the best of the undersigned’s information, knowledge and belief, all Associates have provided on the COI Disclosure Form(s) submitted with this Proposal all disclosures required per the ODOT COI Guidelines.

If applicable, Proposer has, or will have prior to contract execution, a written policy and practice, that meets the requirements described in ORS 279A.112, of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class. (Agency may not enter into a contract with an anticipated contract price of $150,000 or more with a Proposer that does not certify it has such a policy and practice. See additional information and sample policy template.)

Proposer certifies that all contents of the Proposal (including any other forms or documentation, if required under this RFP) and this Proposal Certification Sheet, are truthful and accurate and have been prepared independently from all other Proposers, and without collusion, fraud, or other dishonesty.

Proposer understands that any statement or representation it makes, in response to this RFP, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, made under Price Agreement being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

Proposer acknowledges these certifications are in addition to any certifications required in the Contract/Price Agreement and Statement of Work in Attachment A at the time of Price Agreement execution.

(Print Name and Title)

PROPOSER INFORMATION AND CERTIFICATION SHEET – APPENDIX 1

REFERENCES

REFERENCES FOR COMPARABLE PROJECTS IN SIZE AND SCOPE: Provide 3 references from public transportation agencies or where the proposed system, or similar system has been purchased and is operating. References will be contacted and asked the questions listed below. References are worth up to 300 points.

Each question will be evaluated on a scale of 1 to 10 based on the following criteria:

Ratings Guidelines:

Exceptional 9-10 points: Exceeded expectations and well above average to work with. Very high user satisfaction.

Very Good 7-8 points: Met all expectations and exceeded in some areas.

Satisfactory 4-6 points: Met all contract requirements and/or professional expectations; may have had minor problems but implemented satisfactory corrective actions.

Marginal 1-3 points: Some performance and/or professional expectations not met; ineffective corrective actions for some problems.

Unsatisfactory 0 points: Technical, budget or schedule performance expectations not met. Low user satisfaction.

Rating Scores

PLEASE RESPOND TO EACH OF THE FOLLOWING FOR THE CONTRACTOR AND PROJECT LISTED IN TABLE A:

TOTAL SCORE ______________

Name of Firm:

Reference Contact Person:

Alternate Reference Contact Person:

Project/Contract Title:

Description of Services/Goods provided, including specific equipment being used:

Name of Firm:

Reference Contact Person:

Alternate Reference Contact Person:

Project/Contract Title:

Description of Services/Goods provided, including specific equipment being used:

Name of Firm:

Reference Contact Person:

Alternate Reference Contact Person:

Project/Contract Title:

Description of Services/Goods provided, including specific equipment being used: